Are Fewer Damage Control Laparotomies Associated with a Decrease in the Rate and Severity of Surgical Site Infections?

Authors:
Chelsea Guy Frank, John A. Harvin, Lillian S Kao, Renee W, Green, Stephanie Martinez Ugarte

Body of Abstract:
Background: Local damage control laparotomy (DCL) rates have decreased since the implementation of a multi-faceted quality improvement intervention during the first half of the last decade. Given the association of DCL with both organ space and incisional surgical site infections (SSIs), we hypothesize that SSI rates and severity based on Clavien-Dindo (CD) classification have decreased over the same time period.

Methods: A retrospective study was performed of all patients (>16 years) who underwent trauma laparotomy at a large metropolitan Level 1 Trauma Center from 01/2011-12/2020. Patients who did not survive >48 hours were excluded. The data was divided into period 1 (1/2011-12/2015) and period 2 (1/2016-12/2020). The Center for Disease Control and Prevention definitions of organ space (OS-SSI) and superficial and deep incisional (SD-SSIs) were used. CD classification was further grouped into minor and major, with CD grade 1 (opening the wound) and 2 (antibiotics) considered minor and CD grade ≥ 3a (procedure requiring sedation, single and multiorgan failure, and death) considered major. Univariate and multivariable analyses were performed (p<0.05). Results: Of 1975 patients that met inclusion criteria, the median age was 33 (23, 46) years old. A total of 18% (355) of patients developed an SSI, 18.5% (179) in period 1 and 17.4% (176) in period 2 (P= 0.5). Between periods 1 and 2, there was an increase in injury severity score (ISS, 19 [ IQR 10, 29] vs 21 [IQR 12, 34], P<0.001) and penetrating mechanism of injury (426 (44%) vs. 513 (51%), p=0.002), while there was a decrease in the use of DCL (283 [29%] vs. 153 [15%], P=0.001). Despite the decrease in use of DCL, the rates and severity of SSIs remained stable between the two time periods (Table). Length of hospital stay decreased (LOS, 10 [IQR 6,21] vs 9.5 [IQR 5, 20] P= 0.04). On multivariable analysis, DCL, penetrating mechanism of injury, lower emergency room systolic blood pressure, higher wound classification, large bowel resection, and splenectomy were predictors of CD grade ≥3a SSIs. Conclusions: Contrary to our hypothesis, despite decreases in DCL use, the rates and severity of SSIs after trauma laparotomy in our patient population have not decreased but remained stable over the recent decade. The decreased use of DCLs may have been offset by the increase in penetrating injuries. Other potentially modifiable risk factors need to be identified to be able to impact the frequency and severity of SSIs after trauma laparotomy.